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The facility failed to maintain the exit corridors to be free of obstructions.

1) During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open. 7.2.1.4.3.1

Observation determined the north double set of corridor doors to the Laundry Room opened outward into the exit corridor and extended more than 7 inches from the wall when fully opened.

Failure to maintain the means of egress to be available at all times increases the risk of death or injury due to fire.

The deficiency affected two (2) of numerous corridor doors in the means of egress throughout the facility.

2) Means of egress must be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. The width of means of egress shall be measured in the clear at the narrowest point of the exit component under consideration. Exception: Projections not more than 4 1/2 in. (114 mm) on each side shall be permitted at 38 in. (965 mm) and below. 7.1.10.1, 7.3.2.2

Observation determined a fixed heater located in the corridor by the north exit door in the Link Corridor extended approximately six (6) inches from the corridor wall and protruded into the exit corridor.

Failure to ensure exit access is readily available at all times increases the risk of death or injury due to fire.

This deficiency affected egress from one (1) of six (6) smoke compartments in the facility.

Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 19.3.4.1

A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm and Signaling Code. 9.6.1.3. 2010 NFPA 72, 14.1.1

The facility failed to test the fire alarm system as required.

Review of fire alarm system test records indicated the annual test of the fire alarm system was not performed as required. The most current fire alarm system annual test was conducted on 10/02/2017 and the previous test was conducted on 08/31/2016, exceeding the required annual testing requirement.

Failure to test and maintain the fire alarm system in accordance with NFPA 72 increases the risk of death or injury due to fire.

This deficiency affected one (1) of one (1) fire alarm system. The fire alarm system serves the entire facility.

In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors. Detectors should not be located in a direct airflow or closer than 36 in. from an air supply diffuser or return air opening. 19.3.4.5.1, 9.6.2.10.1.1, NFPA 72 17.7.4.1, A.17.7.4.1

The facility failed to ensure the smoke detection system was in compliance with NFPA 72, National Fire Alarm and Signaling Code.

Observation determined the smoke detector in the East Unit Housekeeping Room was installed within 36 in. of an air supply diffuser.

Failure to install the smoke detection system as required increases the risk of death or injury due to fire.

This deficiency affected one (1) of numerous smoke detectors in the facility. The smoke detection system serves the entire facility.

Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system. 19.3.5.1, 9.7.1.1(1)

The facility failed to install the automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems to provide adequate coverage for all portions of the building.

1) Sprinklers in the high-temperature zone shall be of the high-temperature classification, and sprinklers in the intermediate-temperature zone shall be of the intermediate-temperature classification. NFPA 13 8.3.2, 8.3.2.5(1), Table 8.3.2.5(a)(2)

NFPA 13 requires high-temperature-rated sprinklers within a 7 ft. radius cylinder extending 7 ft. above and 2 ft. below horizontal discharge unit heaters.

Observation determined two (2) sprinklers in the Kitchen installed within 7 ft. of unit heaters were not high-temperature-rated.

2) A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas except where specific sections of NFPA 13 permit the omission of sprinklers. Combustible soffits, eaves, overhangs, and decorative frame elements shall not exceed 4 ft 0 in. (1.2 m) in width. NFPA 13 4.1, 8.15.1.2.18.1

Observation determined:

a) The attached combustible exterior pergola by the Activity Room over 4 feet in width was not protected by the automatic sprinkler system.
b) The attached combustible exterior awning by the South Dining Room over 4 feet in width was not protected by the automatic sprinkler system.

Failure to install the automatic sprinkler system in accordance with NFPA 13 increases the risk of injury and death due to fire.

This deficiency affected three (3) of numerous areas in the facility. The automatic sprinkler system serves the entire facility.

Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems. 19.7.6, 4.6.12, NFPA 25

The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25.

Record review determined:

1) There were two (2) 2' x 2' open grates installed in place of ceiling tile in the Nursing Home Business Office that could delay the activation of the sprinkler system.

2) There were three (3) 2' x 2' open grates installed in place of ceiling tile in the Mezzanine Area that could delay the activation of the sprinkler system.

3) There were two (2) 2' x 4' open grates installed in place of ceiling tile in the corridor by the Vault Storage Room that could delay the activation of the sprinkler system.

4) There were two (2) 2' x 2' open grates installed in place of ceiling tile in the Kitchen that could delay the activation of the sprinkler system.

5) There was a 1' x 1' hole in a ceiling tile in the Activity Room that could delay the activation of the sprinkler system.

6) There were four (4) missing ceiling tiles in the Data Closet in the South Dining Room that could delay the activation of the sprinkler system.

7) Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation. NFPA 25, 5.2.1.1.1

Observation determined the sprinkler above the triple sink in the Kitchen had lost the fluid from the glass bulb.

Failure to inspect, test and maintain the automatic sprinkler system in accordance with NFPA 25 increases the risk of death or injury due to fire.

This deficiency affected six (6) of numerous areas in the facility. The automatic sprinkler system serves the entire facility.